Case of the month

The purpose of this link is to provide examples of interesting test findings obtained on children with central auditory processing, language, reading, or learning disorders. The choice of a specific case presentation is always difficult because every child represents a unique individual and there are as many interesting cases are there are children. What we will present are findings that are likely to be less common, that present special problems of interpretation.

Cases:

Child with abnormal ear advantage and neurologic basis for auditory processing disorder

Child with delay in auditory maturation with standard score discrepancies among intelligence, language and auditory processing results.

________________________________________________

Name: This child
C.A.: 10-3
_______________________________________________________

History:

This child is a pleasant, handsome 10-year-old child who interacts and communicates well with adults. His birth and developmental history are normal. He loves music and has perfect pitch.  In conversation he is reported to do better if engaged visually while speaking to him. His parents report that since Kindergarten he has had difficulty in school, with problems following directions or “listening to instructions.” He is beginning to experience difficulty in following multi-step instructions, sometimes and has difficulty completing tasks as instructed.  His parents report that he is in fifth grade and is “trying very hard to listen.”  Results of intelligence testing found no substantial discrepancy between verbal and performance IQ’s with a full scale IQ in the 90^th %ile with a standard score approximately 120.  He performs in the 90+%ile on standardized psychoeducational tests, however he parents report that this has lead to his relaxed attitude towards study since a lot of material comes naturally.  In spite of his intelligence This child’s grades are slipping and he recently received some F’s.  There is some question by the SLP whether he has attention deficit disorder though the parents feel he does not. He is among the youngest age of children in his class.  Finally, he has no obvious problems with coordination or fine motor control, but he dislikes group sports because most other children are better coordinated, he dislikes physical contact.  His parents describe his handwriting as “atrocious.”

Test Results:

Pure tone threshold testing found thresholds at 5 dB for all frequencies with normal tympanometry.   Speech reception thresholds were 5 dB HL with 100% word discrimination in quiet. 

Results of the SCAN-C Test for Auditory Processing Disorders in Children-Revised were as follows:

Scoring Summary

________________________________________________________

Competing Words Ear Advantage

Results of Filtered Words and Auditory Figure Ground subtests are in the normal range. The Competing words test is “normal” in absolute terms, but the 16^th percentile is low for normal processing. The Competing Words Subtest results were in the 9th percentile. Moreover, the ear advantage scores found an atypical strong right ear advantage. The same finding was obtained on the Competing Words subtest, the Competing Sentences Subtest and the Staggered Spondee Word Test. Ear advantage scores are powerful indicators of hemispheric dominance for language, and maturational based language/learning disorders. The right ear advantage indicates that language is appropriately established in the left cerebral hemisphere but the atypical large right ear advantage in a child approaching eleven years indicates the presence of a developmental delay of the auditory system.

Random Gap Detection Test (RGDT):

The RGDT is a test of temporal processing (auditory timing) ability. Disorders of auditory timing are related to disorders of auditory discrimination, reading and language. This child’s gap detection thresholds of less than 5 milliseconds are normal.

Durations Patterns Test (DPT):

The DPT is a measure of pattern recognition in the time domain, a cortical function reflecting hemispheric interaction between recognition of sound patterns of different duration and providing a linguistic label of what was heard. This child’s responses were completely normal.

Frequency Patterns Test (FPT):

The FPT is a measure of pattern recognition in the frequency (pitch) domain, a cortical function reflecting hemispheric interaction between recognition of sound patterns of different pitch and providing a linguistic label of what was heard. This child’s responses were 100%.

Staggered Spondee Word Test (SSW)

The SSW is a dichotic test of binaural separation. The SSW stimuli represent both competing and non-competing words presented to each ear simultaneously.

The SSW results are abnormal with the number of errors in the left-ear competing condition more than twice the typical finding for a child this age.  When the SSW results are converted to Z scores and percentiles the left competing condition result has a Z score of -4 that is below the 1st percentile. The right competing score Z score equals -1.3 that is approximately the 10th %ile.

Observations of behavioral auditory testing: 

This child’s responses to auditory stimuli were characterized by slow responses that occurred at the end of nearly every response time interval allowed during the standardized tests.  This delayed latency of response indicated that he was always at the “threshold” of understanding.  The need for additional time to process auditory information indicates that listening under complex acoustic conditions, to rapid or distorted speech, is a difficult task that is frustrating and tiring. 

Electrophysiology:

A battery of electrophysiologic tests was administered. They included:

· Auditory Brainstem Evoked Potentials
· Middle Latency Auditory Evoked Potential
· P-100
· P-300

Results of all tests were normal. The P-300 assesses auditory attention at the physiologic level. The P-300 response was present with a normal latency and large amplitude, indicating that attention processes as measured by this technique are completely normal.

Speech Language Evaluation: 

Results of language testing found a total language standard score of 128.  Both his receptive and expressive language was advanced.   On a test of phonological processing he was normal for awareness and memory but low average for rapid naming.  Specifically this child has difficulty whenever he is required to retrieve specific information or to name.  That is, given freedom to talk freely about the world he appears to be very intelligent.  However, when he is required to give specific convergent knowledge his performance is low.  He was in the 9^th stanine for math and the 7^th stanine for reading. 

Summary:

This child was referred for CAPD testing because of history of difficulty listening, missing directions, and doing poorly in school. These difficulties occur even though This child is extremely bright, has good language skills, and is reading above grade level. He is a self-admitted “dawdler.” Results on routine hearing testing found normal hearing thresholds. Tests of auditory processing abilities found normal duration and frequency processing, normal processing in the time domain, and normal auditory processing of minimally distorted speech and speech in noise. Tests of auditory maturation found delays in the development of his central auditory pathways. There are large discrepancies between the standard scores found on intelligence and language testing compared to auditory processing.  These findings confirm that learning through the auditory modality may be difficult because This child’s listening skills are those of a child who is chronologically younger. In addition, This child was slow in responding during behavioral testing.  That is, his responses always came at the end of time intervals allowed for response.  His responses indicated a need for additional time to process auditory information.  His high level of intelligence compensates somewhat for these deficiencies, but may cause him problems because the language closure he utilizes sometimes leads him down the wrong path, and causing him to miss basic specific information, assignments, directions, etc. He was completely attentive throughout testing done on this date, with no evidence of attention deficit. Recommendations for classroom management are discussed below.

Electrophysiologic tests of auditory nervous system function confirm that there is no fundamental physiologic central nervous system disorder, that he is “simply” delayed in auditory maturation. The implication is that his auditory system will continue to mature and he will “catch up” with his peers at some time. Finally, the P-300 auditory evoked potential was normal providing electrophysiologic confirmation of behavioral observations that This child does not have attention deficit disorder.

Recommendations:

Results of this test find normal peripheral hearing, with normal auditory processing for some fundamental perceptual tasks. The delay in auditory maturation found on several tests indicates that This child’s listening ability is his poorest academic strength. Because his auditory processing is not strong This child may hear some information inaccurately. For example, his auditory analysis and synthesis skills may be actually “harmed” by his cognitive ability. Specifically, This child has excellent top down processing. His world knowledge, his knowledge of events, and his linguistic knowledge is at a high level. This child’s processing is at a low level however, so that auditory subskills processing, short-term memory, phonological processing skills are comparatively weak. This child knows to guess when he misses auditory information, but when he guesses he is sometimes wrong, misses information, and does not get complete or accurate directions. This situation is exacerbated by This child self-admitted dawdling.

Some basic classroom management techniques may help This child in classroom activities:

· Provide his teachers with information contained in this report.

· Provide This child preferential seating, close to wherever the teacher does most teaching,

· Identify noise sources, reduce them, and move This child away from them

· Alert This child to changes in topic and supplement group instructions with individual checks of comprehension. 

· Increase one-on-one instruction

· Monitory his auditory comprehension, to be sure he has understood directions, has correct assignments, and understands material covered.

· Break new information into shorter segments

· Assist This child in developing organizational strategies

This child can also help himself by taking responsibility in making the following changes:

· Increase his visual vigilance, watch speakers for information to supplement what is heard

· Increase his vigilance to the task at hand, and reduce the time wasted by dawdling.

·    In addition This child needs to begin moving toward an internal locus of control and ask for clarification of auditory information  when he is unsure or misses instructional material. 

Finally, it was recommend that This child’s auditory processing be rechecked in a year to document the rate of change in maturation.

Child with abnormal ear advantage and neurologic basis for auditory processing disorder

This case is a 7-year-old child referred to our center with a complex history of language, learning, auditory, and attention problems. This child was the product of a normal pregnancy and delivery. He had normal physical development with no significant medical problems. He experienced slow language development with a significant language delay. At 3 years of age he used only an estimated 100 words.

Physical examination: Normal in all respects. It should be noted that his mother described him as always being strongly left hand oriented from his earliest days.

Psychological evaluation: Significant discrepancy between his verbal and performance scores, with verbal IQ at 60 and performance IQ at 122. This child was noted to be eager to participate and cooperative but tired easily and became fidgety. All performance was affected by his lack of impulse control.

Speech and language evaluation: Results of the CELF-R indicate a receptive language score in the 1st percentile and expressive language score in the 3rd percentile. His language scores were similarly depressed on the TACL-3, PLS-3, and Expressive One-Word Picture Vocabulary Test - 3rd edition.

Peripheral hearing testing found normal pure tone thresholds with normal tympanometry.

Central auditory test results included:

SCAN-C composite performance was in the 8th percentile with no performance discrepancy among subtests. Another remarkable finding was a clear left ear advantage for all tests including filtered words, auditory figure ground, competing words, and competing sentences. That is, for all tests, he scored more correct in the left ear than the right. For example, the competing words test found a right ear total raw score of 5 and a left ear total of 14, placing him in the 5th percentile. Similarly, he was able to repeat

Staggered Spondee Word Test found a significant left ear advantage with 90% error on the right competing and 35% error on the left competing conditions.

Auditory Fusion Threshold Test-Revised was not completed - he was unable to perform the test.

Electrophysiologic measures found normal ABR's bilaterally, a normal P-100 and P-200 with abnormal P-300.

Comment: There were several significant findings including the poor language performance and central auditory processing scores. The most significant finding was the strong left ear advantage found on all subtests. This finding is extremely unusual in the typical 7-year-old where a strong right ear advantage is typical. These finding raised the concern of possible left hemisphere lesion so that the pediatrician ordered a MRI. The MRI results were normal with no evidence of any lesion and with normal symmetry of cerebral hemispheres.

The finding of strong left ear advantage is contrary to the normal auditory development of children. In the typical child the right ear scores are substantially better than the left, because of the left hemisphere dominance for language, and the direct right ear to left hemisphere anatomic connection. When a strong left ear advantage is found in a young child the findings indicate the possibility of a lesion of the left hemisphere, lack of a strong dominant hemisphere for language, mixed dominance for language, or right hemisphere dominance. In the absence of a lesion of the brain, the findings indicate a neurologic basis for the language disorder experienced by this child. The findings also help to explain the neurologic basis for the significant verbal-performance discrepancy found on psychological testing.

These test findings are unusual because of the extreme left ear advantage. Our clinical experience indicates that such children have greater language problems, require more intensive remediation, and have a long course of habilitation as a consequence of the neurological basis for their disorder. The findings indicate the need for intensive language remediation to deal with all aspects of language development. His attention problems are a related issue that needs to be managed. Because of the plasticity of the brain this child is likely to improve substantially over time. However the need for intensive language intervention cannot be overemphasized.

In summary, the central auditory test findings obtained on this language delayed child indicate an underlying neurologic basis for the language disorder and indicate directions for intervention.